Case 8 - A Newborn with Vomiting

"I'd
like you to meet my son Jamie who is a week old today. Jamie and I,
and his 2-1/2 year-old brother Jason live with my mother in a house
in a small Iowa town. Jamie's father works at a car wash and I stay
home to take care of the boys."

The Problem / Clinical Presentation
"My story with Jamie started one week ago on a Wednesday when I went
into labor. I had a normal pregnancy with no complications except
that I got the hiccups a lot. My doctor had delivered my son Jason
and he is really good. My doctor was going out of town when the baby
was supposed to be due, so I chose to be induced so he could deliver
the baby. As it turned out, I started going into labor two weeks
before I was due and they helped the labor with the Pitocin. I was in
labor for 15 hours, which was different from my first child who only
took six hours. That night, my beautiful little baby was born."

"When I first fed him with the bottle an hour or so after he was
born, he threw up. I thought maybe he swallowed a lot of phlegm. The
next few times I fed him on Thursday, everything came right back up.
He started getting a little better at keeping his food down late
Thursday. On Friday, when I got released, the pediatrician told me
Jamie would have to stay another day. If the vomiting slowed down,
Jamie could come home Saturday. The pediatrician told me I was
probably feeding Jamie too much, but I don't think I was feeding him
any more than my first child"

"I called on Friday night and Saturday morning and was surprised
to hear that Jamie was still vomiting. While I was visiting him on
Saturday afternoon, he vomited a lot of bright greenish-yellow fluid.
At this point the pediatrician ordered x-rays, and later decided to
send him to the University of Iowa. When the pediatrician told me
this, I had tears streaming down my face. Until then, I didn't really
believe there was anything wrong with him."

"When we got to the University of Iowa, I was initially told that
he may not need surgery, but late Sunday night they took him to the
operating room."

Clinical Physical Exam
Jamie was a vigorous and well-appearing infant with a weight of 2780
grams. Vital signs were stable. His abdominal evaluation showed a
soft, non-tender, non-distended abdomen with good bowel sounds. There
were no masses and no hepatosplenomegaly. Genitourinary examination
showed a circumcised male with bilateral descended testes and no
hernias noted. The rest of his physical examination was normal.

Clinical Differential Diagnosis
The differential diagnosis for a 3 day old with bilious emesis would
include:

Laboratory Differential Diagnosis
These findings indicate that Jamie had normal physiologic parameters
but does not change the differential diagnosis.

Imaging FindingsAbdominal
radiograph was unremarkable. An upper GI series showed that the
duodenal-jejunal junction was abnormally located to the right of the
spine. At this point, there was an abrupt narrowing of the duodenum
with a fine thread of contrast extending inferiorly in a
"corkscrew"-like appearance. Abdominal ultrasound with color Doppler
showed the superior mesenteric vein coursing around the superior
mesenteric artery with a swirl-like appearance.

Operative InterventionThe
patient was taken to the operating room and explored through a
midline incision. Malrotation with midgut volvulus was confirmed. A
Ladd's procedure was performed, placing the colon in the left side of
the abdomen and the small bowel in the right side of the abdomen. An
appendectomy was also performed.

Pathological Findings
Not applicable

Pathological Diagnosis
Not applicable

Treatment Course, Prognosis and Follow-up
"The doctor came out of the operating room and said he removed
Jamie's appendix. I asked what was wrong with his appendix, and the
doctor said it was on the wrong side. So I guess there was a little
more to it than just mucus. It wasn't until a couple of days later
that I understood that his intestines were all turned around."

"It was really unexpected, the local doctors didn't catch it on
the x-rays. It wasn't until they made Jamie swallow the barium that
they knew what was wrong with him. It was hard to believe anything
was wrong. He even had a few bowel movements in the hospital. When I
called the local nurses and told them he had surgery, they were
really surprised."

"It's a long story for a week-old baby. I wondered if it was my
fault, if I didn't take my vitamins enough or eat the right foods.
But I know it's not my fault, and I'm a lot closer to him already.
He's my little blessing."

"Now we're finally on our way home. We've packed his Barney doll,
a present from Jason, and the football and boxing glove from his dad.
Dad calls him his little fighter."

The Approach to the Child With Emesis.

Emesis is the forceful ejection of the stomach contents through
the mouth. Regurgitation is the effortless bringing up of a small
amount of food without discomfort or distress. For a layperson, these
can be hard to separate.

Differential Diagnosis

The differential diagnosis is very extensive and the most common
problems vary with the age of the child. Congenital anomalies and
inborn metabolic errors along with feeding difficulties are more
common in infancy with infectious and systemic disease become more
common in childhood. Adolescence adds the problems such as eating
disorders, drug use and pregnancy. Potentially, any of the problems
listed may be seen at any time.

A complete history should be taken from the patient and/or family.
Attention should be paid to the timing of the emesis in association
with eating, any associated pain or discomfort, changes in eating and
elimination patterns, whether eating or eliminating improves or
worsens the emesis, characteristics of the stool and urine, any
trauma or systemic problems such as changes in mentation or weight
loss, and fever.

The physical examination should emphasize the abdominal
examination, but other areas such as the respiratory, and
genitourinary systems should be closely examined. Additionally, other
systemic signs should be looked for including skin changes and an
erythematous pharynx.

A careful history and physical examination guides all laboratory
and radiographic evaluations. Depending on the age of the patient and
the differential diagnosis, radiographic procedures such as plain
films, ultrasound and contrast studies may be ordered and help
elucidate anatomic problems. If a surgical problem is being
considered, then early consultation with a surgeon should be
considered.

Evaluation

Laboratory evaluation helps to find systemic and infectious
diseases and can help determine secondary problems such as
electrolyte abnormalities caused by copious emesis. Considerations
for the initial laboratory evaluation can include:

Blood

CBC, differential and platelets for evidence of infection or
malignancy

Malrotation With Midgut Volvulus Discussion

Clinical Presentation
The classic case of malrotation with midgut volvulus is a newborn
<1 month old with bilious vomiting. However, malrotation with
midgut volvulus may present as intermittent abdominal pain and/or
vomiting. Malrotation is also associated with other congenital
anomalies such as diaphragmatic hernia, omphalocele and
gastroschisis.

Pathophysiology
Malrotation with midgut volvulus is the failure of the developing
bowel to undergo the usual counterclockwise rotation in the 4th to
10th week of embryogenesis. Peritoneal bands (which normally attach
the bowel to the central body axis posteriorly) compress the
duodenum, partially obstructing it. Because the mesentery is not well
attached, patients are at risk for developing a midgut volvulus.

The term volvulus comes from the Latin word volvere,
meaning to turn or roll. Volvulus refers to complete twisting of a
loop of bowel around its mesenteric attachment, which results in
intestinal obstruction. The superior mesenteric artery can be
compressed leading to ischemia of its distribution, the small bowel
from the duodenal-jejunal junction to mid-transverse colon.

Lab Findings
Electrolyte imbalances may occur secondary to emesis, but there is no
specific laboratory test to confirm the diagnosis of malrotation with
midgut volvulus.

Imaging Findings
The abdominal plain radiograph is usually unremarkable, although
classically it can demonstrate duodenal or small bowel obstruction.
The upper GI exam is the diagnostic test of choice. The normal
position of the duodenal-jejunal junction (DJJ) is at the level of
the duodenal bulb, overlying the left pedicle of the spine or to the
left of the spine. Any other position should be considered to be
abnormal (a low-lying DJJ or a DJJ positioned to the right of the
spine) and demonstrative of malrotation. Volvulus classically appears
on the upper GI as a spiral corkscrew of the duodenum. Volvulus can
also be seen on abdominal ultrasound where the volvulized small bowel
has a "whirled" appearance.

Pathology
none

Differential Diagnosis

Gastrointestinal atresias

Meconium ileus

Hirschsprung disease

Gastro-esophageal reflux

Pyloric stenosis

Intussusception

Inguinal hernia

Treatment
Malrotation with midgut volvulus is a surgical emergency, because
ischemia can lead to small bowel infarction. To relieve the
obstruction, the peritoneal bands (also known as Ladd bands) around
the duodenum are divided. The colon is placed on the left and the
duodenum on the right to broaden the mesentery. An appendectomy is
performed to avoid future confusion if the child has abdominal pain.
This surgical procedure is known as Ladd's procedure.

Prognosis
Return of intestinal function varies with the degree of ischemia.
Children who undergo treatment before development of bowel infarction
usually regain normal function within a few days. For patients with a
bowel infarction, return of normal function may be delayed depending
on the length of infarcted small bowel that must be resected.
Resection of a large section of the small bowel leads to a poor
prognosis.

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